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Li Y, Liu S, Li J, Feng L, Chen J. The effect of prone-position ventilatory strategy among neurology patients with SARS-CoV-2: A cross-sectional survey. Medicine (Baltimore) 2024; 103:e39522. [PMID: 39252238 PMCID: PMC11383716 DOI: 10.1097/md.0000000000039522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 08/09/2024] [Indexed: 09/11/2024] Open
Abstract
Awake-prone position combined with noninvasive ventilation or high-flow nasal cannula ventilation has been shown to be safe in the treatment of patients with moderate to severe ARDS and COVID-19, and may avoid intubation and reduce patient mortality. We conducted a cross-sectional study in a hospital to observe the effect of prone position on neurological patients with SARS-CoV-2. A total of 52 neurological patients with SARS-CoV-2 participated in the survey. Most patients (76.92%) had cerebrovascular disease combined with SARS-CoV-2. After prone position, the oxygen saturation increased by 3.25% ± 3.02%. The number of patients with an oxygen saturation of 95% or more increased by 28.85%. Among the 3 types of neurological diseases, the oxygen saturation improvement values in patients with encephalitis or encephalopathy was the greatest, and cerebrovascular disease was the least. Oxygen saturation improvements did not differ among delivery modes. Prone position nursing can improve the effect of oxygen therapy on patients with neurological diseases combined with SARS-CoV-2 infection. Prone position nursing can slow the need for advanced equipment such as ventilators during the COVID-19 pandemic.
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Affiliation(s)
- Yinping Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
- West China School of Nursing, Sichuan University, Chengdu, China
| | - Shengyi Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jinmei Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Ling Feng
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
- West China School of Nursing, Sichuan University, Chengdu, China
| | - Jing Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
- West China School of Nursing, Sichuan University, Chengdu, China
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Lan L, Ni Y, Zhou Y, Fu L, Wu W, Li P, Yu H, Liang G, Luo F. PEEP-Induced Lung Recruitment Maneuver Combined with Prone Position for ARDS: A Single-Center, Prospective, Randomized Clinical Trial. J Clin Med 2024; 13:853. [PMID: 38337547 PMCID: PMC10856548 DOI: 10.3390/jcm13030853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/28/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
Background: Prone position (PP) and the positive end-expiratory pressure (PEEP)-induced lung recruitment maneuver (LRM) are both efficient in improving oxygenation and prognosis in patients with ARDS. The synergistic effect of PP combined with PEEP-induced LRM in patients with ARDS remains unclear. We aim to explore the effects of PP combined with PEEP-induced LRM on prognosis in patients with moderate to severe ARDS and the predicting role of lung recruitablity. Methods: Patients with moderate to severe ARDS were consecutively enrolled. The patients were prospectively assigned to either the intervention (PP with PEEP-induced LRM) or control groups (PP). The clinical outcomes, respiratory mechanics, and electric impedance tomography (EIT) monitoring results for the two groups were compared. Lung recruitablity (recruitment-to-inflation ratio: R/I) was measured during the PEEP-induced LRM procedure and was used for predicting the response to LRM. Results: Fifty-eight patients were included in the final analysis, among which 28 patients (48.2%) received PEEP-induced LRM combined with PP. PEEP-induced LRM enhanced the effect of PP by a significant improvement in oxygenation (∆PaO2/FiO2 75.8 mmHg vs. 4.75 mmHg, p < 0.001) and the compliance of respiratory system (∆Crs, 2 mL/cmH2O vs. -1 mL/cmH2O, p = 0.02) among ARDS patients. Based on the EIT measurement, PP combined with PEEP-induced LRM increased the ventilation distribution mainly in the dorsal region (5.0% vs. 2.0%, p = 0.015). The R/I ratio was measured in 28 subjects. The higher R/I ratio was related to greater oxygenation improvement after LRM (Pearson's r = 0.4; p = 0.034). Conclusions: In patients with moderate to severe ARDS, PEEP-induced LRM combined with PP can improve oxygenation and dorsal ventilation distribution. R/I can be useful to predict responses to LRM.
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Affiliation(s)
- Lan Lan
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610064, China; (L.L.); (Y.N.); (Y.Z.); (L.F.); (W.W.); (P.L.); (H.Y.); (G.L.)
- State Key Laboratory of Respiratory Health and Multimorbidity, West China Hospital, Sichuan University, Chengdu 610064, China
| | - Yuenan Ni
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610064, China; (L.L.); (Y.N.); (Y.Z.); (L.F.); (W.W.); (P.L.); (H.Y.); (G.L.)
- State Key Laboratory of Respiratory Health and Multimorbidity, West China Hospital, Sichuan University, Chengdu 610064, China
| | - Yubei Zhou
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610064, China; (L.L.); (Y.N.); (Y.Z.); (L.F.); (W.W.); (P.L.); (H.Y.); (G.L.)
- State Key Laboratory of Respiratory Health and Multimorbidity, West China Hospital, Sichuan University, Chengdu 610064, China
| | - Linxi Fu
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610064, China; (L.L.); (Y.N.); (Y.Z.); (L.F.); (W.W.); (P.L.); (H.Y.); (G.L.)
- State Key Laboratory of Respiratory Health and Multimorbidity, West China Hospital, Sichuan University, Chengdu 610064, China
| | - Wentao Wu
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610064, China; (L.L.); (Y.N.); (Y.Z.); (L.F.); (W.W.); (P.L.); (H.Y.); (G.L.)
- State Key Laboratory of Respiratory Health and Multimorbidity, West China Hospital, Sichuan University, Chengdu 610064, China
| | - Ping Li
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610064, China; (L.L.); (Y.N.); (Y.Z.); (L.F.); (W.W.); (P.L.); (H.Y.); (G.L.)
- State Key Laboratory of Respiratory Health and Multimorbidity, West China Hospital, Sichuan University, Chengdu 610064, China
| | - He Yu
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610064, China; (L.L.); (Y.N.); (Y.Z.); (L.F.); (W.W.); (P.L.); (H.Y.); (G.L.)
| | - Guopeng Liang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610064, China; (L.L.); (Y.N.); (Y.Z.); (L.F.); (W.W.); (P.L.); (H.Y.); (G.L.)
- State Key Laboratory of Respiratory Health and Multimorbidity, West China Hospital, Sichuan University, Chengdu 610064, China
| | - Fengming Luo
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610064, China; (L.L.); (Y.N.); (Y.Z.); (L.F.); (W.W.); (P.L.); (H.Y.); (G.L.)
- State Key Laboratory of Respiratory Health and Multimorbidity, West China Hospital, Sichuan University, Chengdu 610064, China
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Use of Cardio-Pulmonary Ultrasound in the Neonatal Intensive Care Unit. CHILDREN 2023; 10:children10030462. [PMID: 36980020 PMCID: PMC10047372 DOI: 10.3390/children10030462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 02/11/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023]
Abstract
Cardiopulmonary ultrasound (CPUS), the combination of lung ultrasound (LUS) and targeted neonatal echocardiography (TnECHO)AA, may offer a more appropriate approach to the challenging neonatal cardiovascular and respiratory disorders. This paper reviews the possible use of CPUS in the neonatal intensive care unit (NICU).
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Martinsson A, Houltz E, Wallinder A, Magnusson J, Lindgren S, Stenqvist O, Thorén A. Inspiratory and end-expiratory effects of lung recruitment in the prone position on dorsal lung aeration - new physiological insights in a secondary analysis of a randomised controlled study in post-cardiac surgery patients. BJA OPEN 2022; 4:100105. [PMID: 37588783 PMCID: PMC10430825 DOI: 10.1016/j.bjao.2022.100105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/20/2022] [Indexed: 08/18/2023]
Abstract
Background Cardiac surgery produces dorso-basal atelectasis and ventilation/perfusion mismatch, associated with infection and prolonged intensive care. A postoperative lung volume recruitment manoeuvre to decrease the degree of atelectasis is routine. In patients with severe respiratory failure, prone positioning and recruitment manoeuvres may increase survival, oxygenation, or both. We compared the effects of lung recruitment in prone vs supine positions on dorsal inspiratory and end-expiratory lung aeration. Methods In a prospective RCT, 30 post-cardiac surgery patients were randomly allocated to recruitment manoeuvres in the prone (n=15) or supine position (n=15). The primary endpoints were late dorsal inspiratory volume (arbitrary units [a.u.]) and left/right dorsal end-expiratory lung volume change (a.u.), prone vs supine after extubation, measured using electrical impedance tomography. Secondary outcomes included left/right dorsal inspiratory volumes (a.u.) and left/right dorsal end-expiratory lung volume change (a.u.) after prone recruitment and extubation. Results The last part of dorsal end-inspiratory volume after extubation was higher after prone (49.1 a.u.; 95% confidence interval [CI], 37.4-60.6) vs supine recruitment (24.2 a.u.; 95% CI, 18.4-29.6; P=0.024). Improvement in left dorsal end-expiratory lung volume after extubation was higher after prone (382 a.u.; 95% CI, 261-502) vs supine recruitment (-71 a.u., 95% CI, -140 to -2; n=15; P<0.001). After prone recruitment, left vs right predominant end-expiratory dorsal lung volume change disappeared after extubation. However, both left and right end-expiratory volumes were higher in the prone group, after extubation. Conclusions Recruitment in the prone position improves dorsal inspiratory and end-expiratory lung volumes after cardiac surgery. Clinical trial registration NCT03009331.
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Affiliation(s)
- Andreas Martinsson
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Erik Houltz
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Andreas Wallinder
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jesper Magnusson
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Pulmonary Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sophie Lindgren
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Ola Stenqvist
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Anders Thorén
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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Chioma R, Amabili L, Ciarmoli E, Copetti R, Villani PG, Natile M, Vento G, Storti E, Pierro M. Lung UltraSound Targeted Recruitment (LUSTR): A Novel Protocol to Optimize Open Lung Ventilation in Critically Ill Neonates. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9071035. [PMID: 35884018 PMCID: PMC9317513 DOI: 10.3390/children9071035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/06/2022] [Accepted: 07/09/2022] [Indexed: 12/12/2022]
Abstract
This study investigated the effectiveness of an original Lung UltraSound Targeted Recruitment (LUSTR) protocol to improve the success of lung recruitment maneuvers (LRMs), which are performed as a rescue approach in critically ill neonates. All the LUSTR maneuvers, performed on infants with an oxygen saturation/fraction of inspired oxygen (S/F) ratio below 200, were included in this case−control study (LUSTR-group). The LUSTR-group was matched by the initial S/F ratio and underlying respiratory disease with a control group of lung recruitments performed following the standard oxygenation-guided procedure (Ox-group). The primary outcome was the improvement of the S/F ratio (Delta S/F) throughout the LRM. Secondary outcomes included the rate of air leaks. Each group was comprised of fourteen LRMs. As compared to the standard approach, the LUSTR protocol was associated with a higher success of the procedure in terms of Delta S/F (110 ± 47.3 vs. 64.1 ± 54.6, p = 0.02). This result remained significant after adjusting for confounding variables through multiple linear regressions. The incidence of pneumothorax was lower, although not reaching statistical significance, in the LUSTR-group (0 vs. 14.3%, p = 0.15). The LUSTR protocol may be a more effective and safer option than the oxygenation-based procedure to guide open lung ventilation in neonates, potentially improving ventilation and reducing the impact of ventilator-induced lung injury.
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Affiliation(s)
- Roberto Chioma
- Dipartimento Universitario Scienze della Vita e Sanità Pubblica, Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (R.C.); (G.V.)
| | - Lorenzo Amabili
- Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, 9712 CP Groningen, The Netherlands;
| | - Elena Ciarmoli
- Department of Pediatrics, ASST Vimercate, Vimercate Hospital, 20871 Vimercate, Italy;
| | - Roberto Copetti
- Emergency Department, Latisana General Hospital, 33053 Udine, Italy;
| | - Pier Giorgio Villani
- Department of Critical Care, Maggiore Hospital, 26100 Cremona, Italy; (P.G.V.); (E.S.)
| | - Miria Natile
- Neonatal Intensive Care Unit, Azienda Sanitaria Romagna, Infermi Hospital Rimini, 47923 Rimini, Italy;
| | - Giovanni Vento
- Dipartimento Universitario Scienze della Vita e Sanità Pubblica, Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (R.C.); (G.V.)
| | - Enrico Storti
- Department of Critical Care, Maggiore Hospital, 26100 Cremona, Italy; (P.G.V.); (E.S.)
| | - Maria Pierro
- Neonatal and Paediatric Intensive Care Unit, M. Bufalini Hospital, AUSL Romagna, 47521 Cesena, Italy
- Correspondence: ; Tel.: +39-0547352844
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Martinsson A, Houltz E, Wallinder A, Lindgren S, Thorén A. Lung recruitment in the prone position after cardiac surgery: a randomised controlled study. Br J Anaesth 2021; 126:1067-1074. [PMID: 33602580 DOI: 10.1016/j.bja.2020.12.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Atelectasis after cardiac surgery is common and promotes ventilation/perfusion mismatch, infection, and delayed discharge from critical care. Recruitment manoeuvres are often performed to reduce atelectasis. In severe respiratory failure, recruitment manoeuvres in the prone position may increase oxygenation, survival, or both. We compared the effects of recruitment manoeuvres in the prone vs supine position on lung aeration and oxygenation in cardiac surgical patients. METHODS Subjects were randomised to recruitment manoeuvres (40 cm H2O peak inspiratory pressure and 20 cm H2O PEEP for 30 s) in either the prone or supine position after uncomplicated cardiac surgery. The co-primary endpoints were lung aeration (end-expiratory lung volume measured by electrical impedance tomography (arbitrary units [a.u.]) and lung oxygenation (ratio of arterial oxygen partial pressure to fractional inspired oxygen [Pao2/FiO2 ratio]). Secondary outcomes included postoperative oxygen requirement and adverse events. RESULTS Thirty subjects (27% female; age, 48-81 yr) were recruited. Dorsal lung tidal volume was higher after prone recruitment manoeuvres (363 a.u.; 95% confidence intervals [CI], 283-443; n=15) after extubation, compared with supine recruitment manoeuvres (212 a.u.; 95% CI, 170-254; n=15; P<0.001). Prone recruitment manoeuvres increased dorsal end-expiratory lung volume by 724 a.u. (95% CI, 456-992) after extubation, compared with 163 a.u. decrease (95% CI, 73-252) after supine recruitment manoeuvres (P<0.001). The Pao2/FiO2 ratio after extubation was higher after prone recruitment manoeuvres (46.6; 95% CI, 40.7-53.0) compared with supine recruitment manoeuvres (39.3; 95% CI, 34.8-43.8; P=0.04). Oxygen therapy after extubation was shorter after prone (33 h [13]) vs supine recruitment manoeuvres (52 h [22]; P=0.01). No adverse events occurred. CONCLUSIONS Recruitment manoeuvres in the prone position after cardiac surgery improve lung aeration and oxygenation. CLINICAL TRIAL REGISTRATION NCT03009331.
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Affiliation(s)
- Andreas Martinsson
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Erik Houltz
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Andreas Wallinder
- Department of Cardiothoracic Surgery, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sophie Lindgren
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Thorén
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Fioretto JR, Pires RB, Klefens SO, Kurokawa CS, Carpi MF, Bonatto RC, Moraes MA, Ronchi CF. Inflammatory lung injury in rabbits: effects of high-frequency oscillatory ventilation in the prone position. J Bras Pneumol 2019; 45:e20180067. [PMID: 30916116 PMCID: PMC6715165 DOI: 10.1590/1806-3713/e20180067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 08/12/2018] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To compare the effects that prone and supine positioning during high-frequency oscillatory ventilation (HFOV) have on oxygenation and lung inflammation, histological injury, and oxidative stress in a rabbit model of acute lung injury (ALI). METHODS Thirty male Norfolk white rabbits were induced to ALI by tracheal saline lavage (30 mL/kg, 38°C). The injury was induced during conventional mechanical ventilation, and ALI was considered confirmed when a PaO2/FiO2 ratio < 100 mmHg was reached. Rabbits were randomly divided into two groups: HFOV in the supine position (SP group, n = 15); and HFOV with prone positioning (PP group, n = 15). For HFOV, the mean airway pressure was initially set at 16 cmH2O. At 30, 60, and 90 min after the start of the HFOV protocol, the mean airway pressure was reduced to 14, 12, and 10 cmH2O, respectively. At 120 min, the animals were returned to or remained in the supine position for an extra 30 min. We evaluated oxygenation indices and histological lung injury scores, as well as TNF-α levels in BAL fluid and lung tissue. RESULTS After ALI induction, all of the animals showed significant hypoxemia, decreased respiratory system compliance, decreased oxygenation, and increased mean airway pressure in comparison with the baseline values. There were no statistically significant differences between the two groups, at any of the time points evaluated, in terms of the PaO2 or oxygenation index. However, TNF-α levels in BAL fluid were significantly lower in the PP group than in the SP group, as were histological lung injury scores. CONCLUSIONS Prone positioning appears to attenuate inflammatory and histological lung injury during HFOV in rabbits with ALI.
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Affiliation(s)
- Jose Roberto Fioretto
- . Disciplina de Pediatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
| | | | - Susiane Oliveira Klefens
- . Disciplina de Pediatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
| | - Cilmery Suemi Kurokawa
- . Disciplina de Pediatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
| | - Mario Ferreira Carpi
- . Disciplina de Pediatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
| | - Rossano César Bonatto
- . Disciplina de Pediatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
| | - Marcos Aurélio Moraes
- . Disciplina de Pediatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
| | - Carlos Fernando Ronchi
- . Disciplina de Pediatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
- . Departamento de Fisioterapia, Universidade Federal de Uberlândia, Uberlândia (MG) Brasil
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Koulouras V, Papathanakos G, Papathanasiou A, Nakos G. Efficacy of prone position in acute respiratory distress syndrome patients: A pathophysiology-based review. World J Crit Care Med 2016; 5:121-36. [PMID: 27152255 PMCID: PMC4848155 DOI: 10.5492/wjccm.v5.i2.121] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 01/11/2016] [Accepted: 03/07/2016] [Indexed: 02/06/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a syndrome with heterogeneous underlying pathological processes. It represents a common clinical problem in intensive care unit patients and it is characterized by high mortality. The mainstay of treatment for ARDS is lung protective ventilation with low tidal volumes and positive end-expiratory pressure sufficient for alveolar recruitment. Prone positioning is a supplementary strategy available in managing patients with ARDS. It was first described 40 years ago and it proves to be in alignment with two major ARDS pathophysiological lung models; the "sponge lung" - and the "shape matching" -model. Current evidence strongly supports that prone positioning has beneficial effects on gas exchange, respiratory mechanics, lung protection and hemodynamics as it redistributes transpulmonary pressure, stress and strain throughout the lung and unloads the right ventricle. The factors that individually influence the time course of alveolar recruitment and the improvement in oxygenation during prone positioning have not been well characterized. Although patients' response to prone positioning is quite variable and hard to predict, large randomized trials and recent meta-analyses show that prone position in conjunction with a lung-protective strategy, when performed early and in sufficient duration, may improve survival in patients with ARDS. This pathophysiology-based review and recent clinical evidence strongly support the use of prone positioning in the early management of severe ARDS systematically and not as a rescue maneuver or a last-ditch effort.
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Cornejo R, Romero C, Ugalde D, Bustos P, Diaz G, Galvez R, Llanos O, Tobar E. High-volume hemofiltration and prone ventilation in subarachnoid hemorrhage complicated by severe acute respiratory distress syndrome and refractory septic shock. Rev Bras Ter Intensiva 2015; 26:193-9. [PMID: 25028955 PMCID: PMC4103947 DOI: 10.5935/0103-507x.20140028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 04/21/2014] [Indexed: 12/29/2022] Open
Abstract
We report the successful treatment of two patients with aneurismal subarachnoid
hemorrhage complicated by severe respiratory failure and refractory septic shock
using simultaneous prone position ventilation and high-volume hemofiltration. These
rescue therapies allowed the patients to overcome the critical situation without
associated complications and with no detrimental effects on the intracranial and
cerebral perfusion pressures. Prone position ventilation is now an accepted therapy
for severe acute respiratory distress syndrome, and high-volume hemofiltration is a
non-conventional hemodynamic support that has several potential mechanisms for
improving septic shock. In this manuscript, we briefly review these therapies and the
related evidence. When other conventional treatments are insufficient for providing
safe limits of oxygenation and perfusion as part of basic neuroprotective care in
subarachnoid hemorrhage patients, these rescue therapies should be considered on a
case-by-case basis by an experienced critical care team.
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Affiliation(s)
- Rodrigo Cornejo
- Unidade de Terapia Intensiva, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Carlos Romero
- Unidade de Terapia Intensiva, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Diego Ugalde
- Unidade de Terapia Intensiva, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Patricio Bustos
- Departamento de Neurologia e Neurocirurgia, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Gonzalo Diaz
- Unidade de Terapia Intensiva, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Ricardo Galvez
- Unidade de Terapia Intensiva, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Osvaldo Llanos
- Unidade de Terapia Intensiva, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Eduardo Tobar
- Unidade de Terapia Intensiva, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
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Santos CL, Samary CDS, Fiorio Júnior PL, Santos BL, Schanaider A. Pulmonar recruitment in acute respiratory distress syndrome. What is the best strategy? Rev Col Bras Cir 2015; 42:125-9. [DOI: 10.1590/0100-69912015002010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 05/20/2014] [Indexed: 12/15/2022] Open
Abstract
Supporting patients with acute respiratory distress syndrome (ARDS), using a protective mechanical ventilation strategy characterized by low tidal volume and limitation of positive end-expiratory pressure (PEEP) is a standard practice in the intensive care unit. However, these strategies can promote lung de-recruitment, leading to the cyclic closing and reopening of collapsed alveoli and small airways. Recruitment maneuvers (RM) can be used to augment other methods, like positive end-expiratory pressure and positioning, to improve aerated lung volume. Clinical practice varies widely, and the optimal method and patient selection for recruitment maneuvers have not been determined, considerable uncertainty remaining regarding the appropriateness of RM. This review aims to discuss recent findings about the available types of RM, and compare the effectiveness, indications and adverse effects among them, as well as their impact on morbidity and mortality in ARDS patients. Recent developments include experimental and clinical evidence that a stepwise extended recruitment maneuver may cause an improvement in aerated lung volume and decrease the biological impact seen with the traditionally used sustained inflation, with less adverse effects. Prone positioning can reduce mortality in severe ARDS patients and may be an useful adjunct to recruitment maneuvers and advanced ventilatory strategies, such noisy ventilation and BIVENT, which have been useful in providing lung recruitment.
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Abstract
PURPOSE OF REVIEW Supporting patients with acute respiratory distress syndrome (ARDS) using a low tidal volume strategy is a standard practice in the ICU. Recruitment maneuvers can be used to augment other methods, like positive end-expiratory pressure and positioning, to improve aerated lung volume. Clinical practice varies widely, and optimal method and patient selection for recruitment maneuvers have not been determined. RECENT FINDINGS Recent developments include experimental and clinical evidence that a stepwise extended recruitment maneuver may match the improvement in aerated lung volume seen with sustained inflation traditionally used, with less adverse effects. Positioning and other chest wall modifications may be useful adjuncts to recruitment maneuvers. In addition, evidence from clinical studies in the operating room suggests that recruitment maneuvers, as a component of an open lung strategy, may be helpful for mechanically ventilated patients with normal lungs. SUMMARY As a component of ventilation strategy for patients with ARDS, the use of recruitment maneuvers, especially a stepwise maneuver, in addition to adequate positive end-expiratory pressure and appropriate positioning, is suggested by currently available data. Until their effect on clinical outcomes is further defined, the use of recruitment maneuvers in ARDS and other settings will continue to be guided by individual clinician experience and patient factors.
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Ray K, Bodenham A, Paramasivam E. Pulmonary atelectasis in anaesthesia and critical care. ACTA ACUST UNITED AC 2014. [DOI: 10.1093/bjaceaccp/mkt064] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Parto S, Shafaghi S, Khoddami-Vishteh HR, Makki SM, Abbasidezfuli A, Daneshvar A, Sheikhy K, Faeghi J, Ghorbani F, Parsa T, Najafizadeh K. Efficacy of recruitment maneuver for improving the brain dead marginal lungs to ideal. Transplant Proc 2014; 45:3531-3. [PMID: 24314951 DOI: 10.1016/j.transproceed.2013.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Because of the shortage of lungs for transplantation, finding the suitable lungs in brain-dead donors is an important issue. Recruitment maneuver is a strategy aimed at re-expanding collapsed and edematous lung tissue. The aim of this study was to assess the efficacy of this maneuver on improving marginal lungs for transplantation. METHODS From 127 brain-dead potential donor which were evaluated for lung donation in Masih Daneshvari Organ Procurement Unit of Tehran, Iran, 31 (25%) had marginal lungs for transplantation. These donors had normal chest X ray or bilateral infiltration and had PaO2 200-300 mm Hg with FIO2 100%. The recruitment maneuver was performed and arterial blood gas was obtained before and after maneuver. The maneuver lasts for 2 hours with continuous check of O2 saturation and patient's hemodynamic during. Finally, patients with normal bronchoscopy and PaO2/FIO2 >300 mm Hg were considered good candidates for lung transplantation. The frequency (%) and mean ± SD were used for description of variables and the Wilcoxon test was used for comparison between pre- and post-maneuver PaO2 with FIO2 100%. RESULTS The mean ± SD of PaO2/FIO2 with 100% FIO2 of patients before and after recruitment were 239 ± 62 and 269 ± 91, respectively. Recruitment maneuver could convert 10 marginal lungs (32%) to appropriate ones (PaO2 > 300) and finally 8 lungs were transplanted. CONCLUSIONS Findings of this study showed that recruitment maneuver could convert inappropriate lungs to appropriate ones in one third of brain-dead patients who had marginal lung condition. So, it is recommended that this maneuver is considered in the assessment protocol of lungs for donation.
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Affiliation(s)
- S Parto
- Lung Transplantation Research Center, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Alveolar recruitment during mechanical ventilation – Where are we in 2013? TRENDS IN ANAESTHESIA AND CRITICAL CARE 2013. [DOI: 10.1016/j.tacc.2013.06.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Algaba Á, Nin N. Maniobras de reclutamiento alveolar en el síndrome de distrés respiratorio agudo. Med Intensiva 2013; 37:355-62. [DOI: 10.1016/j.medin.2013.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 01/29/2013] [Accepted: 01/30/2013] [Indexed: 01/14/2023]
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Stable respiratory activity requires both P/Q-type and N-type voltage-gated calcium channels. J Neurosci 2013; 33:3633-45. [PMID: 23426690 DOI: 10.1523/jneurosci.6390-11.2013] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
P/Q-type voltage-gated calcium channels (Ca(v)2.1) play critical presynaptic and postsynaptic roles throughout the nervous system and have been implicated in a variety of neurological disorders. Here we report that mice with a genetic ablation of the Ca(v)2.1 pore-forming α(1A) subunit (α(1A)⁻/⁻) encoded by CACNA1a (Jun et al., 1999) suffer during postnatal development from increasing breathing disturbances that lead ultimately to death. Breathing abnormalities include decreased minute ventilation and a specific loss of sighs, which was associated with lung atelectasis. Similar respiratory alterations were preserved in the isolated in vitro brainstem slice preparation containing the pre-Bötzinger complex. The loss of Ca(v)2.1 was associated with an alteration in the functional dependency on N-type calcium channels (Ca(v)2.2). Blocking N-type calcium channels with conotoxin GVIA had only minor effects on respiratory activity in slices from control (CT) littermates, but abolished respiratory activity in all slices from α(1A)⁻/⁻ mice. The amplitude of evoked EPSPs was smaller in inspiratory neurons from α(1A)⁻/⁻ mice compared with CTs. Conotoxin GVIA abolished all EPSPs in inspiratory neurons from α(1A)⁻/⁻ mice, while the EPSP amplitude was reduced by only 30% in CT mice. Moreover, neuromodulation was significantly altered as muscarine abolished respiratory network activity in α(1A)⁻/⁻ mice but not in CT mice. We conclude that excitatory synaptic transmission dependent on N-type and P/Q-type calcium channels is required for stable breathing and sighing. In the absence of P/Q-type calcium channels, breathing, sighing, and neuromodulation are severely compromised, leading to early mortality.
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Prone positioning improves oxygenation in adult burn patients with severe acute respiratory distress syndrome. J Trauma Acute Care Surg 2012; 72:1634-9. [PMID: 22695433 DOI: 10.1097/ta.0b013e318247cd4f] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Prone positioning (PP) improves oxygenation and may provide a benefit in patients with acute respiratory distress syndrome (ARDS). This approach adds significant challenges to patients in intensive care by limiting access to the endotracheal or tracheostomy tube and vascular access. PP also significantly complicates burn care by making skin protection and wound care more difficult. We hypothesize that PP improves oxygenation and can be performed safely in burn patients with ARDS. METHODS PP was implemented in a burn intensive care unit for 18 patients with severe refractory ARDS. The characteristics of these patients were retrospectively reviewed to evaluate the impact of PP on Pao2:FiO2 ratio (PFR) during the first 48 hours of therapy. Each patient was considered his or her own control before initiation of PP, and trends in PFR were evaluated with one-way analysis of variance. Secondary measures of complications and mortality were also evaluated. RESULTS Mean PFR before PP was 87 (± 38) with a mean sequential organ failure assessment score of 11 (± 4). PFR improved during 48 hours in 12 of 14 survivors (p < 0.05). Mean PFR was 133 (± 77) immediately after PP, 165 (± 118) at 6 hours, 170 (± 115) at 12 hours, 214 (± 126) at 24 hours, 236 (± 137) at 36 hours, and 210 (± 97) at 48 hours. At each measured time interval except the last, PFR significantly improved. There were no unintended extubations. Facial pressure ulcers developed in four patients (22%). Overall, 14 survived 48 hours (78%), 12 survived 28 days (67%), and six survived to hospital discharge (33%). CONCLUSIONS PP improves oxygenation in burn patients with severe ARDS and was safely implemented in a burn intensive care unit. Mortality in this population remains high, warranting investigation into additional complementary rescue therapies. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Goal-oriented respiratory management for critically ill patients with acute respiratory distress syndrome. Crit Care Res Pract 2012; 2012:952168. [PMID: 22957224 PMCID: PMC3432327 DOI: 10.1155/2012/952168] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2012] [Accepted: 07/19/2012] [Indexed: 02/07/2023] Open
Abstract
This paper, based on relevant literature articles and the authors' clinical experience, presents a goal-oriented respiratory management for critically ill patients with acute respiratory distress syndrome (ARDS) that can help improve clinicians' ability to care for these patients. Early recognition of ARDS modified risk factors and avoidance of aggravating factors during hospital stay such as nonprotective mechanical ventilation, multiple blood products transfusions, positive fluid balance, ventilator-associated pneumonia, and gastric aspiration can help decrease its incidence. An early extensive clinical, laboratory, and imaging evaluation of “at risk patients” allows a correct diagnosis of ARDS, assessment of comorbidities, and calculation of prognostic indices, so that a careful treatment can be planned. Rapid administration of antibiotics and resuscitative measures in case of sepsis and septic shock associated with protective ventilatory strategies and early short-term paralysis associated with differential ventilatory techniques (recruitment maneuvers with adequate positive end-expiratory pressure titration, prone position, and new extracorporeal membrane oxygenation techniques) in severe ARDS can help improve its prognosis. Revaluation of ARDS patients on the third day of evolution (Sequential Organ Failure Assessment (SOFA), biomarkers and response to infection therapy) allows changes in the initial treatment plans and can help decrease ARDS mortality.
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Abstract
Management of acute respiratory failure is an important component of intensive care. In this review, we analyze 21 original research articles published last year in Critical Care in the field of respiratory and critical care medicine. The articles are summarized according to the following topic categories: acute respiratory distress syndrome, mechanical ventilation, adjunctive therapies, and pneumonia.
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Positioning of patients with acute respiratory distress syndrome: combining prone and upright makes sense. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:1019. [PMID: 22182757 PMCID: PMC3388640 DOI: 10.1186/cc10560] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Positional strategies have been proposed for mechanically ventilated patients with acute respiratory distress syndrome. Despite different physiological mechanisms involved, oxygenation improvement has been demonstrated with both prone and upright positions. In the previous issue of Critical Care, Robak and colleagues reported the first study evaluating the short-term effects of combining prone and upright positioning. The combined positioning enhanced the response rate in terms of oxygenation. Other benefits, such as a reduction in ventilator-associated pneumonia and better enteral feeding tolerance, can potentially be expected.
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